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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603385
Report Date: 07/29/2024
Date Signed: 07/29/2024 02:44:40 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/22/2022 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220722163041
FACILITY NAME:COMMONWEALTH ROYALE GUEST HOMEFACILITY NUMBER:
197603385
ADMINISTRATOR:KITT, GARYFACILITY TYPE:
740
ADDRESS:150 S. COMMONWEALTH AVETELEPHONE:
(213) 382-6381
CITY:LOS ANGELESSTATE: CAZIP CODE:
90004
CAPACITY:99CENSUS: 84DATE:
07/29/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Anna RempelTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident sustained multiple wounds (unstageable) while in the facilities care
Staff did not adequately manage resident's glucose
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted unannounced subsequent complaint visit to deliver investigation findings for the above stated allegations. LPA met with Administrator Anna Rempel and explained the reason for the visit.

The investigation consisted of: During the initial visit conducted on 07/26/22, LPA Gonzalez collected copies of Staff and Resident rosters, reviewed Resident 1's file (R1), and collected copies of documents pertinent to the investigation. LPA conducted an interview with Assistant Administrator Anna Rempel and collected contact information for R1's Home Health Agency - Supportive Homecare. LPA additionally conducted a tour of entire facility inside and out with Assistant Administrator Anna Rempel and did not observe any immediate Health & Safety concerns during the visit. On 08/02/22, LPA requested and received home health records


(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 28-AS-20220722163041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COMMONWEALTH ROYALE GUEST HOME
FACILITY NUMBER: 197603385
VISIT DATE: 07/29/2024
NARRATIVE
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dated 06/11/22 – 07/01/22 for R1 via email from Supportive Home Health. On 03/08/23, LPA mailed/ emailed Investigative Subpoena Duces Tecum to hospital requesting hospital records. On 10/11/23, LPA re-emailed subpoena and sent an email inquiring on status of subpoena and didn't receive a response. On 11/14/23, LPA completed an Investigations Branch Service Request requesting assistance with obtaining hospital records. On 12/27/23, LPA received R1's hospital records from Special Investigator Eliza Jackson. On 01/31/24, LPA called home health agency to request additional documents for dates 07/02/22 – 07/18/22. On 02/02/24, LPA followed up with home health agency regarding request for additional documents. On 02/07/24, LPA submitted a Clinical Consult Referral with hospital records and partial home health records for review by department Program Clinical Consultant (PCC). On 02/08/24, LPA received additional documents from home health agency dated 07/02/22 – 07/18/22 and forwarded the records on 02/14/24 to the department PCC for review. On 04/23/24, LPA conducted a telephone interview with Administrator Rempel and a telephone interview with Supportive Home Health Care Director of Patient Care Services. LPA emailed additional information to PCC. On 06/11/24, LPA conducted a Subsequent Visit and collected copies of Staff and Resident rosters, conducted interviews with Administrator Anna Rempel, S1-4 and R2-8. LPA conducted a tour of the facility and observed residents in care. LPA toured and inspected a total of 8 resident rooms and also tested the facility signal system. On 06/21/24, LPA Gonzalez revised and resubmitted Clinical Consult Referral for PCC review with hospital records and home health records. On 07/03/24, LPA requested and received facility shower schedules for January – July 2022 and Medication Administration Records (MARs) for June and July 2022 from the facility. LPA forwarded the records and resident/ staff interviews to PCC for review. On 07/19/24, LPA received completed PCC referral.

The investigation revealed the following: Regarding allegation of, Resident sustained multiple wounds (unstageable) while in the facilities care, it is alleged that R1 was neglected by the facility. R1 was hospitalized on 07/18/22 and had several wounds that appeared to be unattended, and the facility Administrator allegedly stated that R1’s wound had just started over the weekend before R1 was hospitalized and were treated with heel protectors and lotion. However, when R1 was hospitalized, they had some wounds that were reported as unstageable. Interviews conducted with facility staff revealed that R1 did not have any pressure injuries before being hospitalized. Staff stated that the resident was seen by home health twice a day and they were not instructed that resident needed to be repositioned or given any other instructions regarding caring for any wounds. Staff stated that R1 was able to shift around in their bed as well as get off the bed. They stated that R1 did have very dry skin, so they often had to moisturize their skin
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20220722163041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COMMONWEALTH ROYALE GUEST HOME
FACILITY NUMBER: 197603385
VISIT DATE: 07/29/2024
NARRATIVE
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with lotion. Staff also stated that they check on all residents every two hours and immediately if a resident uses their call button requesting assistance. Staff stated that incontinence care is provided every two hours and as needed, if a resident uses the call button requesting assistance. Administrator stated that R1 was seen twice a day by home health and that facility staff cared for R1's needs as needed and always followed the doctors orders as well as home health nurse orders. She stated that facility staff are trained in providing adequate care and supervision, as well as the importance of providing assistance with Activities of Daily Living (ADLs) for any resident that requires assistance with ADL's. She stated that staff were providing R1 with shower assistance twice a week and staff had not reported that they had observed any changes with R1's skin. Per medical records review, the home health agency indicated that R1's skin condition did not vary from 06/11/22 - 07/17/22 indicating that their skin was cool, dry, clammy and also stated that the nurse performed a comprehensive nursing assessment of all body systems, blood sugar was checked via fingerstick, diabetic foot exams were performed with no abnormal findings noted. The nurse also noted that they prepared and gave the insulin subcutaneously and skin was intact. On 07/18/22, records indicate that the home health nurse documented that R1's skin was cool, dry, clammy, pallor and wounds were observed. The nurse documented the wound care per physician's orders. The nurse also noted weakness and poor fluid intake at which time the nurse decided to call the physician who ordered that R1 be taken to the hospital. Interviews conducted with 7 out of 7 residents revealed that the facility staff are helpful, check on them often and respond to the call system right away. One resident was bed bound at the time of LPA visit, and they stated that they do not have any concerns, staff check on them every 2 hours or sooner and when they need assistance, they use the signal system, and staff respond quickly. This resident stated that they can shift around without assistance. Residents requiring shower assistance stated that staff give them their showers as scheduled and they do not have any complaints. LPA observed staff tending to residents and observed that residents appeared clean. LPA also tested the signal system in 8 resident rooms and verified that the signal system is working, and staff responded in less than two minutes. Based on statements gathered from interviews conducted with staff, facility residents, LPA observations and record review, there was not enough supportive evidence to concur with the reported allegation.

For allegation, Staff did not adequately manage resident's glucose, it is alleged that R1's A1c level was at 17 when they were hospitalized on 07/18/22. Administrator stated that R1's glucose was checked daily and insulin was administered as well and staff know to call the doctor if R1's glucose is very high. Interview conducted with facility administrator revealed that R1 was provided adequate and timely care at all times.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20220722163041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: COMMONWEALTH ROYALE GUEST HOME
FACILITY NUMBER: 197603385
VISIT DATE: 07/29/2024
NARRATIVE
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She stated that R1 was seen twice a day by home health and that facility staff cared for R1's needs as needed and always followed the doctors orders as well as home health nurse orders. Per medical records review, Supportive Home Health Care Re-Certification Form dated 06/07/22, indicated the continuance of skilled nursing visits for R1 and also indicated the physician ordered Home Health Care to monitor blood glucose twice a day and administer insulin by subcutaneous injection in the morning and in the evening. Home Health Care records also reported blood sugars that did not match the blood sugars at the hospital emergency department. A complaint against Supportive Home Health Care by California Department of Public Health (CDPH) was investigated regarding R1's blood sugars recorded from 06/11/22 - 07/18/22 and the hospital emergency department's blood sugar results. The records revealed that R1's blood sugar were taken twice a day by home health and they did not ever measure over 300mg/dL, and there was no evidence of the home health nurses reporting any sings or symptoms of high blood sugar to R1's primary care physician. CDPH report dated 04/17/24 was unsubstantiated based on interviews and record review. Based on interviews conducted with facility staff and record review, there was not enough supportive evidence to concur with the reported allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.



Exit interview held. A copy of the report was provided to Administrator Anna Rempel.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4